| Objective:To study the correlation of serum homocysteine（Hcy）level with the severity of acute pulmonary thromboembolism（APE）,and to explore the influencing factors of HHcy in patients with APE.Methods:From August 2020 to April 2021,we collected 231 patients in the Cardiology department of our hospital,which were diagnosed with APE according to the clinical symptoms,D-Dimer levels and the results of pulmonary artery CTA.In the next morning after admission,serum levels of homocysteine（Hcy）,folic acid and vitamin B12 were detected in fasting state.According to serum homocysteine levels,all patients are divided into HHcy group（Hcy ≥15 umol/L）and normal Hcy group（Hcy<15 umol/L）.According to hemodynamic situation and s PESI score,all patients with APE are divided into non-high-risk group,high-risk group,low-risk group（s PESI score =0）and medium-risk group（s PESI score ≥1,s PESI =0 but combined with increased right ventricular diameter and/or elevated cardiac biomarkers）.Furthermore,according to the results of pulmonary artery CTA and different prognosis,the patients are divided into central embolism group and non-central embolism group,double pulmonary embolism group and single pulmonary embolism group,adverse events group and non-adverse events group,recurrent VTE group and non-recurrent VTE group.Then we use the appropriate statistical methods to explore the relationship between serum Hcy level and the severity of APE.In addition,to study the influencing factors of HHcy in patients with acute pulmonary embolism.Results:1)Comparison between high-risk group and non-high risk group:The median age of patients in high-risk group is 59.46 years old,which is younger than that in non-high-risk group,the difference is statistically significant（P<0.05）.But there are no significant differences in gender and past medical history between the two groups（P>0.05）.Compared with patients in non-high risk group,heart rate and WBC count of patients in high-risk group were significantly increased（P<0.05）,and serum vitamin B12 level of patients in high-risk group was significantly decreased（P<0.05）.But there were no significant differences in BMI,FBG,WBC,HB,PLT,TC,TG,LDL-C,HDL-C,Scr,UA,Mb,and C reactive protein between two groups（P>0.05）.The proportion of abnormal R or T wave in precordial leads,double pulmonary embolism and central embolism were significantly higher than that in non-high risk group（P<0.05）,but there were no significant difference in RVD,RVD/LVD,PAP,proportion of S1Q3T3 and complete right bundle branch block between two groups（P>0.05）.M（Q25,Q75）of serum homocysteine in high risk group patients was16.67（10.32,62.68）umol/L,which was significantly higher than that in non-high-risk group（P<0.05）.Stratified by age and gender,this difference was still significant in middle-aged and elderly patients（≥45years old）and male patients（P<0.05）,but not significant in young patients（<45 years old）and female patients（P>0.05）.Excluding confounding factors,serum Hcy level,age,heart rate and WBC count are taken into the binary multi-factor Logistic regression analysis,the results show that: Elevated serum Hcy level（OR=1.044,95%CI: 1.021-1.067,P<0.001）and heart rate（OR=1.030,95%CI:1.002-1.059,P<0.05）are influencing factors of high risk stratification in patients with APE.Furthermore,ROC curve shows that the AUC of homocysteine is 0.643（95%CI:0.497-0.789,P=0.022）,the maximum value of yoden index is 0.37,and when the serum Hcy critical value is22.22umol/L,the sensitivity and specificity respectively are 50% and87%.The serum Hcy level can help identify and predict high-risk APE patients,but the accuracy is low.2)Comparison between low-risk group and medium-risk group:All hemodynamically stable patients with APE are divided into low-risk group and medium-risk group,according to s PESI score,right ventricular diameter,cardiac biomarkers.The average age of patients in low risk group is 62.01±13.69 years old,and that in medium risk group is66.44±12.84 years old.There is a statistical difference in age between two groups（P<0.05）.There are no significant differences in gender,past medical history and combined disease between two groups（P>0.05）.In medium-risk group,the levels of WBC count,uric acid,serum creatinine,myoglobin and lactic acid were significantly higher than that in low-risk group（P<0.05）;Platelet count in medium risk group was significantly lower than that in low risk group（P<0.05）.There are no significant differences in the levels of BMI,FBG,HB,TC,TG,LDL-C,HDL-C,folic acid,vitamin B12 and CRP between two groups（P>0.05）.M（Q25,Q75）of serum Hcy of patients in low risk group was 11.92（9.79,16.55）umol/L,which was no significant difference in medium-risk group（P<0.05）.Stratified by age and gender,there is still no significant difference between two groups（P>0.05）.2)The differences in the prevalence of HHcy and serum Hcy level among different subgroups:The prevalence of HHcy in patients with central embolization was42.98%（49 cases）,and the serum Hcy level’s M（Q25,Q75）was 13.46（10.20,18.53）umol/L,which was no significant difference in peripheric embolization（P>0.05）.The prevalence of HHcy in patients with double pulmonary embolism was 44.30%（70 cases）,which was significantly higher than that in single pulmonary embolism group（P<0.05）;but the serum Hcy levels betwennt two groups weren’t significantly different.The prevalence of HHcy in patients who had adverse event while in hospital was 48.72%（19 cases）,and the serum Hcy level’s M（Q25,Q75）was 14.21（10.65,23.00）umol/L,which were no difference in non-adverse event group（P>0.05）.The prevalence of HHcy in recurrent VTE group was 38.89%（7cases）,and the serum Hcy level’s M（Q25,Q75）was 13.71（10.82,17.70）umol/L,which was not significantly different in non-recurrent VTE group（P>0.05）.4)Comparison between HHcy group and NHcy group:In HHcy group,the proportion of male is higher than that in NHcy group（P<0.05）,but there is no significant difference in age between two groups（P>0.05）.The most common initial clinical symptoms of APE in both two groups were chest pain and dyspnea,then common initial clinical symptoms were syncope,hemoptysis,lower limb swelling and pain,and fever.There are no statistically significant differences between the two groups in initial clinical symptoms and past medical history（P>0.05）.The levels of plasma BNP,myoglobin,uric acid and serum creatinine in HHcy group are significantly higher than that in NHcy group（P<0.05）.and the levels of vitamin B12 and folic acid are significantly lower than that in NHcy group（P<0.05）.There are no significant differences in BMI,arterial oxygen partial pressure,partial pressure of carbon dioxide,the levels of FBG,WBC,HB,PLT,TC,TG,LDL-C,HDL-C,troponin and C-reactive protein between two groups（P>0.05）.There are no statistically significant differences between the two groups in proportion of deep venous thrombosis,right ventricular size,right ventricular diameter/left ventricular diameter,S1Q3T3,complete right bundle branch block,abnormal R or T wave（P>0.05）.5)Analysis of influencing factors of HHcy in patients with APE:Let’s take HHcy as the dependent variable,the gender,folic acid and vitamin B12 are taken into binary multi-factor Logistic regression analysis.The results showed that: Low folic acid levels（OR=0.725,95%CI: 0.625-0.840,P <0.001）and Vitamin B12 levels（OR=0.998,95%CI: 0.996-0.999,P =0.007）are independent risk factors increasing the occurrence rate of HHcy in patients with APE.Conclusion:1)The level of serum Hcy in patients in the high risk group is significantly higher than that in the non-high risk group,especially in male,middle-aged and senior people.2)Serum Hcy is an influential factor in high-risk APE patients,but its value in the identification and prediction of high-risk APE patients is low.3)There is no significant difference in serum Hcy level between low risk and medium risk group in patients with APE.4)Serum Hcy level is not associated with the occurrence of adverse events and recurrence of VTE.5)The decreased levels of folic acid and vitamin B12 are independent risk factors of HHcy in patients with APE. |
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